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BI?tsdBR I.:.N ,';FRUC'IIONS:
<br /> I. One F(3RM '13"shall be crrmplotc;cl for each Vank for all NEW PERKt`I ,TsitRmirr(-HANIGHS, REMOYr I�S nd Or sW
<br /> other TANK IbIFRMA11ON CHANGE
<br /> 2. 'I` is form should be completed by either the PER,*rI'AJ1PIJCANT or the LOCAL AGENCY UNDERGROUNDTANK
<br /> I SPEC11t) t
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard point writing;instrument,you are making 3 copies,;
<br /> `I'OP OF I RM-W ILK ONLY opfl?rnim*
<br /> 1. Mark an (X) in the box Meat to the item that best dcscribos the reason the farm is being,completed.
<br /> 2. Indicate the DBA or EYascility ram w!,c re the to f is instatled,
<br /> A, Indicate otvness task II) # « Ifthere i.4 a tarok number that is used by the owmer to identify the tank(ex.A1370,99),
<br /> B. Indicate the mitre of the company that manufactured the tank(ex.,AC'MT� `AN Ml',C'i).
<br /> C. Indicate the year the tank was installed (ex. 1987 .
<br /> I). Indicate the tank capacity in gallons(ex.25,(.W or ',1.0,000 etc,).
<br /> & 1. If MC)'I"OR VEHICLE E FUll,"t,;check box I and eornp?cte ite is B
<br /> 1 If not NIappropriate Ibox.L,'I"w I INET,check:the appropriate box in Section A and complete items It R
<br /> 13. Chock
<br /> C. Check the type of MC)TOR VEHICLE FUEL(if box I is checked in A).
<br /> 1). Print the chemical name of the hazardous substance sto,rcd in the tarok and the C.A.S.#. (C hernical Abstract Service
<br /> number),if box 1.is Nor checked in A.
<br /> TI[. TANK CDONSTFRUC CION-MARK ONE, rITIN ONLY IN Im A,11,C&D
<br /> 1. Check only one item inTYPE t1I,S`S I ENC'I`;iNK'txXIT'T AL, I a I"RIOR LINING and CORROSION I'ttO l'.C"I IC)"m,
<br /> 1 Tf 4)'1'111-s ., print in the space;provided,
<br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable,
<br /> 2 If UNKNOWN,circle; or if OTTER, print it spaceI rovidcd.
<br /> 3. Indicate the LEAK PFTF',C."I1C:)ty s tenr(s) used to comply with the monitoring;requirement four the piping.
<br /> 1.. Indicate the LEAK I"I Irl I'IC)ti system(s) used to comply with the monitoring requirements for the tank.
<br /> VI. I'Nke"OI MA110N ONTANK PERMANEWItY C,0,1911)ITS PJ C:II
<br /> 1. I-IS TMA'I7;[) I3ATI L.PgF USE »M(')^-I-JJ/ EA (January, 1988 or 01/88).
<br /> 2. 1 5T'IMATED QUAN111'1'.`Y of HAZARDOUS SUBS"T'i\NC E remaining in the tank(in C:iallons).
<br /> 3. WAS TANK TI11.h2)w1"'ni INI.RT MA'I:` RIAL,t (,'heck 'Yes"or'NO'.
<br /> 1L3§l'RU °ITC)1t FOR"11 F LO(Al,.AG CII—IS
<br /> The stage under-round Stora e tank identifier tif,'m ttarmmer is composed of the t,vo digit county number,the three di-it jtrrissh 6 rr
<br /> number, the six digit facility number and the six digh sack number, The county and jurisdiction numbers are predetermined and
<br /> can ,be obtained by calling the State Board (ptb}739-2421. Th facility number crust be the same;as shown in form 'XThe
<br /> tank number may be assigned by the local agency; hoWccr, this aiumt)e�r recast be numerical and cannot containan alphabct. If
<br /> the local agency prefers the State Pard to assign the tarok number,please leave it blank.
<br /> 'I' S'ITIE SPON s`1STan'1'o '111oF'111E LOCAL AGE,, C1Y`m/v I1 TTTE
<br /> AC(. I ('Y f)17'1 I1?INIl'C)3 743'IC N, '111E rl OCAL AGENCY IS LSPO SI.II13 FOR 11COMPLE-ITON OF 1111
<br /> 'LOCAJ..AGENCY USE ONLY'INFORMA'ITON BOX AND FOR 1138 ARDI' I I ONEk)121a 14"AND W)GKI t I
<br /> FORM-13'(sa)`I`ll 711F,FOLLOWING INN rat#1)T1.nS,S.
<br /> 1`ATT t) FYI IIrCII
<br /> 1�0BOX 527
<br /> PARAMOUNT',CA(Xrj'ri
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